7. What are the main concerns that you would like orthodontics to accomplish?

Has your child ever been evaluated or had orthodontic treatment before?*

Yes

No

Have there been any injuries to the face, mouth, teeth or chin?*

Yes

No

Please explain:*

List any musical instruments played:

Have adenoids or tonsils been removed?*

Yes

No

Has your child been informed of any missing or extra permanent teeth?*

Yes

No

Has your child ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?*

Yes

No

Does your child brush his/her teeth daily?*

Yes

No

Floss his/her teeth daily?*

Yes

No

Child's Physician*

Child's Physician Phone*

Is your child currently under the care of a physician?*

Yes

No

Has puberty begun?*

Yes

No

Has menstruation begun? (Girls)

Yes

No

Please describe your child's current physical health:*

Good

Fair

Poor

Please list all drugs that your child is currently taking:*

Please list all drugs that your child is allergic to:

8. Has your child ever had any of the following medical problems?

Abnormal Bleeding*

Yes

No

Allergies to Any Drugs*

Yes

No

Allergies to Latex/Metals*

Yes

No

Allergies to Plastic*

Yes

No

Any Hospital Stays*

Yes

No

Any Operations*

Yes

No

Asthma*

Yes

No

Bruxism/Grinding*

Yes

No

Cancer*

Yes

No

Clenching*

Yes

No

Congenital Heart Defect*

Yes

No

Convulsions/Epilepsy*

Yes

No

Diabetes*

Yes

No

Handicaps/Disabilities*

Yes

No

Head and Neck Pain*

Yes

No

Headaches*

Yes

No

Hearing Impairment*

Yes

No

Heart Murmur*

Yes

No

Hemophilia*

Yes

No

Hepatitis*

Yes

No

HIV+/ AIDS*

Yes

No

Keloids*

Yes

No

Kidney/Liver Problems*

Yes

No

Rheumatic/Scarlet Fever*

Yes

No

Sleep Apnea*

Yes

No

Snoring*

Yes

No

TMJ Pain*

Yes

No

Tuberculosis(TB)*

Yes

No

ADD/ADHD/Aspergers*

Yes

No

Please discuss any medical problems that your child has had:

9. Does/did your child have any of the following habits?

Clenching/Grinding Teeth*

Yes

No

Lip Sucking/Biting*

Yes

No

Mouth Breather*

Yes

No

Nail Biting*

Yes

No

Nursing Bottle Habits*

Yes

No

Speech Problems*

Yes

No

Thumb/Finger Sucking*

Yes

No

Tongue Thrust*

Yes

No

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.